Another sample CPE Verbatim: Depression and Significance

I thought I’d throw another of my verbatims out there as a sample, Feel free to read over and comment. Just remember that I OK all comments so don’t bother being an idiot.

Samuel Blair Verbatim 4

Date of visit: 11/18/10

Length of visit: 30 minutes (1:15p-1:45p)

1) Theme: An emotional theme that came up during this visit was one of disappointment and sadness. I felt this coming through the visit and the patient expressed herself in such a way that I was able to empathize with her rather quickly. I felt her disappointment and sadness during the visit and left me feeling both with and for her.

2) Preliminary Information: This patient is new to me but not new to hospice. I am taking over a few patients from one of our chaplains, and it was recommended that I see this patient as she has expressed interest in spiritual support and seems to gain a lot from it. I knew very little about her, but knew that she was Catholic, enjoyed hymns and scripture, and seems lonely. She was admitted to hospice under “decline in clinical status”, which a very vague term indicating that the person’s health is failing for no specific reason other than general decline and age. The case manager had recently mentioned to me that this patient might benefit from twice-monthly visits, which is more than our usual. I planned on going in to introduce myself and develop some rapport with her, see about her needs and wants, and then plan from there what next steps would be.

I had just come from a long visit with another new patient, and I was feeling tired as well as frustrated and angry because this prior patient’s dog bit me twice on my leg as I was leaving his home. I was practicing uptime during the day by leaving my car radio off while traveling and being more accepting of the relative silence. This helped keep me focused on what I was doing and not distracted.

3) Observations: Mrs. S was in bed, the room was dim. Staff escorted to me to her room and said that they had just laid her down as she said that she was tired. They noted nothing else out of the ordinary. Her TV was off, there were a couple bulletin boards in her room with pictures of family and a couple cards. She did not have a roommate present at the time. When the nurse awoke her to introduce me she seemed scared and anxious, not knowing who I was or what was going on. She did not have dentures in and spoke fairly softly, which made her hard to understand at times.

4) Visit narrative:

C1: Hello, Mrs. S?

P1: Yes?

C2: Hi, I’m Sam Blair. I’m a minister with Gateway, the extra nurses that come by to see you. Pastor Wayne who sees you told me that you might like a visit. (sitting down at bedside)

P2: Yes. He told me to stay in bed so I don’t fall. He said I should stay in bed. (seems a bit anxious)

C3: How are you today?

P3: Good. I’m tired though.

C4: Really?

P4: Yes. I’m 95.

C5: Really?

P5: Yes. I turned 95 this past weekend.

C6: Wow! Well happy birthday! How was it?

P6: Well, I thought it would be a big thrill…but it wasn’t.

C7: Well you don’t look 95.

P7: Everybody says that. But there’s nothing really new to say. Nothing new at all.

C8: Oh. I’m sorry to hear that.

(silence)

C9: How long have you been here?

P9: A couple of months. It feels like always.

C10: Do you like it?

P10: I’m not wild about it.

C11: I see…it’s not where you’d like to be.

P11: Home is where the heart is.

C12: And you’re heart’s not here.

P12: No.

C13: Where were you before?

P13: At my own place. But I had to give it up.

C14: Oh?

P14: My daughter said it was too much for me and that I couldn’t live there on my own anymore. So I had to come here. She didn’t know it was so dumpy (smiles).

C15: (laughs) I see.

P15: I miss her.

C16: Does she see you?

P16: Yes, but she’s busy. She has two sons in their late 20’s. They’re doing well. They have very good jobs.

C17: I see.

P17: (pauses) I’d like to live with her.

C18: I see. You’re pretty disappointed that you can’t.

P18: Yes. I’ve had a lot of disappointments in my life.

(pauses)

P19: I’m cold (brings up blankets)

C19: It’s pretty cold outside.

P20: Is it?

C20: Yep. Some people like the cold though…

P21: They’re athletic

C21: Really?

P22: Yes. Athletic people like the cold.

C22: Yes I guess they do. I’m not athletic though.

P23: (smiles) I like Florida.

C24: Really?

P24: It’s the easy life.

C25: Ah! Did you ever live there?

P25: No. I was never able to.

C26: Hm.

(silence)

C27: You seem to have had a lot of disappointments in life.

P27: (sighs) I just wish things could have been better. I wish I could be out of here. I’d like to live with my daughter. (pauses) I’m sorry, but I’m getting tired.

C28: I see. Well I’d like to stop by and see you again. Would that be OK?

P28: Yes. (makes direct eye contact)

C29: I bet you have some wonderful stories.

P30: Well I don’t think…it’s not that interesting…

C30: I don’t think you could live 95 years and not have some wonderful stories. I think that some of the most interesting stories are the ones that don’t seem interesting to you. To you they’re mundane but to other people they’re amazing.

P31: (smiles)

C31: Before I go would you like your TV on?

P32: No, I can’t watch tv. I used to like to read, but now I can’t see well. I had cataracts and I could only have one removed. They had to take me in an ambulance and it was horrible. I went this way and the other way…

C32: The ride was pretty scary for you.

P32: It was. I couldn’t go and get my other eye done. But now they’re different.

C33: And that has to be hard for you too.

P33: Yes. I used to read Dickens. My favorite was David Copperfield.

C34: Really?

P34: Yes.

C35: I haven’t read much Dickens, but I did just read a book by Jack London, “The Sea Wolf”.

P35: London…he wrote about Alaska. I remember that the Europeans liked Jack London more and Americans tended to like Dickens.

C36: Would you like me to get you some books on tape for you? I like to listen to books on tape when I’m driving.

P36: No thanks.

C37: How about a radio?

P37: No. I could ask my daughter, but I couldn’t get one

C38: I could ask to get one here.

P38: No. It would just be another disappointment.

(pause)

P39: I’m tired. I’d really like to close my eyes and rest.

C39: Ok. Before I go, would you like me to pray with you?

P40: (makes eye contact again) Yes.

C40: And you’re Catholic, right?

P41: (looks surprised) Yes.

C41: Don’t worry. Wayne told me. I didn’t just figure it out. Would you like to pray the Lord’s Prayer?

P42: Yes I would.

(we pray the Lord’s prayer together. She has points where she loses track and I try to match her pace).

C42: God bless you. I was very glad to meet you. I’ll stop by and see you again.

P43: I’d like that…I’d like that.

C43: Have a good day.

5) Summary: The patient was more open with me than I expected at first. I also did not expect her to be so alert and oriented. Most of my patients have at least some degree of dementia, and she was quite sharp and insightful. Her comments on Dickens and literaure took me quite off guard. Themes of sadness, loneliness, lost dreams and hopelessness came through early on in our conversation. Through most of the conversation she did not make direct eye contact, choosing to either look down or through the corner of her eye. I sensed some sensitivity and afterward noted that I did not use touch as much as I tend to do. She gave me a lot of feedback during the conversation through her body language, as well as through some very direct answers at times – her “Yes” had some passion behind it.

Another theme that came through me to her was one of significance. I recognized that a challenge that many of the elderly have is one of looking back on their life as one of significance and fruitfulness or one of failure and disappointment. I wanted to reflect her value in a meaningful way, recognizing that her age was milestone that needed to be recognized and one which could be reframed in a way that made it no longer a “disappointment” but a source of satisfaction and meaning. As this is a theme I visit often in my own life as well (meaningfulness) I felt a strong connection with her and at the end I felt that she was a pretty remarkable person who was struggling with a lot of depression.

After the visit I checked her chart at the nurse’s station and found that many commented on her depression, that she refused care at times, and was not eating at times. I reviewed the chaplain’s notes as well and he did not note any depression, instead focusing on her religious traditions and interactions around that. I also followed up with our social worker after the visit and she felt that the patient may have had some mental illness in her past that was never treated. She also stated that of the patient’s four children only one is involved and the rest are estranged. She had sought treatment from a psychiatrist in the past but frequently changed doctors.

6) Self-evaluation: I thought the visit went well and it ended up being the best one I had this week. There were a few times where I think we both felt a bit uneasy and I tried to wait for her to break the silence rather than interject on my own. I also noted a few times when we both went off track (talk about the weather) but I used these moments to try to join with her as well. I felt her depression and sadness and wanted to reflect an acceptance of herself as she was. I felt sad for her but also felt that the visit had brightened her day a little which made me satisfied and happy. She expressed a desire to continue the relationship which affirmed what I felt as well. I also felt that my uptime during the trip was helpful in that I felt less distracted and a little more refreshed than I usually do that time of day.

7) Theological/Religious Themes: I did not ask her much about her faith or religious background. I had a general knowledge of them but as the visit went on I did not see them as a primary focus. I expect as time goes on this may become more a part of our conversation, and perhaps a means to come to some reconciliation with herself and God. I wondered if her disappointment was leveled at herself, fate or God. I feel that she may have some anger directed toward God for her lot in life, and she probably directs this inward. As this is a common theme in my own life (self-directed guilt and shame) her own struggle resonated with my own.

8) Future plans: I plan on visiting this patient again in two weeks, after Thanksgiving. I would like to look in to getting her a radio or some books on tape, but before I do so I would like to further develop our relationship. I would like to further investigate her own faith and beliefs and while I don’t expect to make grand changes in her life I do hope to effect some positive influences which could make her feel more accepted and worthy of care. Of course, even if just that happens, that could be considered a grand change for Mrs. S.

CPE stands for Clinical Pastoral Education. It’s something that many clergy undertake in seminary in order to develop their pastoral care skills, develop empathy and learn how to handle crisis situations such as sudden loss. It also helps students understand their own needs and spiritual pain. It also helps address theological concerns such as why people suffer.

Hi Sam. Thanks for posting this. I really appreciated reading the verbatim. I’ve never seen one before although I know that this format was used for CPE. What stood out for me was your ability to establish rapport with her and how you were able to engage her by making regular conversation (e.g., asking about her life and her interests) but you also carefully weaved in therapeutic techniques (e.g. exploratory questions, reframing). You met her where she was at and matched her pace. You also tried to help her see the value and meaning in her own life.

I cannot compare my volunteer work as a visitor at a palliative unit to your work as a chaplain, but one of the most important things I learned from this work was the importance of just being with the person wherever they are at and the follow them from there. I initially had expected (and even hoped….)that patients would want to talk about existential and/or religious/spiritual issues but most of the time people just seemed to enjoy talking about everyday life and being able to tell a bit about their story (if they were alert enough and cognitively able to). I also tried to always highlight their strengths, abilities, etc. (e.g., “sounds like you are a very devoted mom” or “you have had some really interesting jobs) especially in those who did seem to be more sad, disappointed, or defeated by life. It made me think of “Dignity Therapy” that I recently came across as a psychotherapeutic approach for working with clients at the end-of-life, and I’m hoping to learn more about it.

Sorry for my long-winded response. I just love talking about this stuff and the opportunity to exchange these ideas with other professionals.

Thanks very much for your comments! I have some experience with narrative therapy (http://www.narrativetherapycentre.com/narrative.html) and find it a useful way to turn normal conversation into more existential work. This was one of my favorite patients and was very sad when we had to discharge her – which happens on hospice sometimes.

I think you can compare your volunteer work however, as it sounds like you’re doing the same thing for the same reasons.